Sleepy Residents Mailbag

One of the things that never ceases to amaze me is the response we receive to repeat episodes of WCBA.  Our Sleepy Residents show last week was a rebroadcast of one from last season on sleep deprivation among residents.  Many of you were astonished that the problem of sleep deprivation in medicine hasn't been licked.

Dan Furlan writes:  "As a Human Resources Professional, I have occasion to refer to the Employment Standards Code in different provinces. Is the medical profession exempt from these for some reason? I will look into it.  Over time, I have also been served very well by the medical profession, having been patched up after many sports injuries, cancer and other afflictions. I have been quite curious about this particular issue over the past few years.  I wondered if it had continued, and how labour law addressed it.  The continuation of some of the practices you highlighted is unacceptable (outdated tradition and culture be damned).  Just as in drinking and driving, smoking, and harassment in the workplace, "There is nothing as powerful as then idea whose time has come." Old practices die slowly; however, people are like that. Perhaps the legal action taken in Quebec indicates the route to go. Also, after a few lawsuits from dissatisfied patients, perhaps the malpractice insurance companies may have some influence. Continuing these practices certainly sounds like "careless and reckless disregard".  Whatever happened to "first of all, do no harm"?

"On a related point, customer expectations have risen dramatically in the past generation or two.  They continue to do so. As pleased as I am with the medical service I have received, I am also much more aware of, and likely to respond to bad service when it happens. I expect others have arrived at this point as well. "

Cynthia Tansley of Victoria sent this email:  "It's a sobering fact, that what we expect of young doctors, to stay awake for long hours, is actually a recognised form of torture:  sleep deprivation!   Also any parent of a restless new baby will relate to the anxiety, depression and poor decision making that comes with insufficient sleep.  Something that might get the attention of attending physicians and administrators:  when a patient is signing a consent form for elective surgery, we should also have us sign a consent stating we are willing to have a doctor look after us if she or he has worked more than a certain number of hours without sleep.  It would place the decision firmly in the hands of patients.   My guess is that it would only take a few refusals to get everyone's attention. "

So would cancelling lots of surgeries, Cynthia.  The concept behind "just don't do it if you're too tired" is seductive yet simplistic.  I know the culture of medicine all too well.  You can't expect everyone to be daytime rested and smart 24/7.

By far, we received the biggest response to my conversation with ER colleague Dr. Mike Wansbrough about using the drug Modafinil to increase alertness during night shifts. 
Brian Kearns of St. Albert writes:  "I followed your programme with great interest and found it enlightening with regard to a very important issue relating to patient safety, not to mention physician health and morale.  However, I was amazed with the concluding part of the episode when you seemed to endorse the use of Modafinil.  You were dealing with an issue that clearly has to do with human resource management, health and safety, but then chose to introduce the use of a prescription drug, normally used to treat narcolepsy.  I cannot imagine a more contradictory and perverse way of addressing the problems you outlined.  Typical of the medical profession, if surgery does not work - try the quick fix of drugs.  This will hardly deal with the issue in the long term and will likely contribute to more exhaustion, possible mental health problems and drug abuse.  Give your head a shake and deal with this as a behavioural and human resource management issue affecting the health of patients and physicians alike."

Brian, the rest of the show dealt extensively with efforts to deal with the problem.  Cutting resident hours is one approach.  It's all well and good to cut resident hours and make them go home.  But as we found, some residents don't go home when they're supposed to.  And even when they do, there are real concerns that cutting resident hours robs them of valuable clinical experience. 

And then, once residents go out into the world as attending physicians, they soon discover there are no safeguards against sleep deprivation.   That's not only true of big cities; it's especially true of health care delivery in small towns.  If you're one of two attending surgeons serving a small community, you might find yourself on call and awake for an entire weekend. Quite simply, you cannot invent safeguards and rules that will eliminate sleep deprivation. Many point to the airline industry as an example of one that embraces a culture of safety.  However, despite that culture, there are still instances even today when pilots and air traffic controllers fall prey to sleep deprivation.

Given that, I think the health care system would be foolish not to consider any strategy that can boost alertness safely. Modafinil is one such strategy.  The drug works on the hypothalamus to increase wakefulness and ability to concentrate a night.  In a paper published in the New England Journal of Medicine in 2005, sleep researcher Charles Czeisler found that Modafinil reduced excessive sleepiness in shift workers.

In a paper published in the Mayo Clinic Proceedings, Czeisler and colleagues found that Armodafinil - a sister compound - likewise boosted wakefulness and concentration in shift workers. 

There are potential side effects with either drug.  The decision to use them should not be taken lightly. But in my opinion, it's counterproductive to fall back on antidrug doctrine and ideology.  You can't solve the problem of sleep deprivation in health care by good habits and rules and admonitions alone. 

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